Now Reading: Choices Deplete Executive Function (and implications for Electronic Health Record use)

One of the great things about a blog is that I can write about incomplete thoughts. Sometimes I’m right, sometimes I’m wrong, and sometimes I’m 6 months ahead of my time. Doesn’t matter how things end up, disk space is cheap.

This idea is around some of the changes that have happened in clinician workflow since the advent of the electronic health record, and some research that caught my eye that might be related. I first found this article while reading a blog post about how long meetings may deplete the ability to make sound choices. After reading the research article, I’m not sure I agree with the conclusion that long meetings are a waste of time, though (here’s a competing point of view from the Toyota World) but I digress.

What the researchers tested in their work was whether there is an “executive function” from which people draw to self-regulate and make good choices. Self-regulation comes in the form of staying persistent on tasks and being alert, instead of going on to doing something else, or pointing out an error. An example they used was putting a subject in a room and asking them to watch a video after engaging in a depleting task (making choices), and seeing how long it took for them to point out that the video was fuzzy. I can think of many analogies to the functioning of a physician/clinician taking care of patients such as spotting the lab abnormality for a person.

This is different from “mental fatigue” which usually results from repetitive less thoughtful tasks. This is about choosing among alternatives and making a commitment. The studies were clever and demonstrated that with more choices being made, persistence and alertness to abnormal conditions decreased.

Why this caught my eye with respect to Electronic Health Records

When we went from paper based review of results to electronic health records, I saw a dramatic increase in efficiency of delivery of results – the instant they were recorded, they were delivered. Previously, they would be batched daily and reviewed all at once. The batching occurred on a patient-by-patient basis, so a physician would review all the results by a patient all at once. One physician once asked me, “why can’t the computer system similarly batch results and send them to me, say every few hours?” My I.T. brain said that this was defeating built in functionality and probably unsafe, but I continued to think about this when I practiced and saw other people practice…..

What I noticed was that with this increased efficiency, clinicians could find themselves reviewing and re-reviewing a patient’s record multiple times throughout the day, as a result came in. In other words, the electronic health record systems of today were being set up to worry about getting the result from the lab to the doctor (and to the patient) but not necessarily to worry about creating the right decision making environment.

This study lends a little bit of thought to that idea. If a person goes from reviewing maybe 50-60 patients’ worth of data a day to several times that due to the disaggregation brought on by electronic system, could their executive functioning decrease? And therefore, what we see as unsafe, throttling the electronic health record system, actually may create a safety issue where the data is most relevant, in the hands of patients and physicians?

These systems bring the same philosophy of result delivery to patients as well (when they deliver to patients). The difference is that the patient’s executive function may depleted 10-12 times a day, rather than 150-200 times.

A quote from the Vohs’ study:

the current research found that the hangover effect from making choices persisted over the course of at least a few minutes, and other research on ego depletion has found effects of up to 45 minutes postmanipulation.

Whenever I practiced, I usually left at the end of the day with a “brain fog” – I wonder if this is what’s going on. Of course, the wonderful thing about primary care is that relationships persist – for me this heightened my interest in involving the patient and family in every decision and in the ability to revisit it in any way that was convenient for them (secure e-mail, phone, in person, and an after visit summary on the spot of course). The power of the doctor’s brain is expanded dramatically by leveraging the one of the patient and their family.

There’s a simpler writetup of this work available at Scientific American as well. Interestinigly, marketers are also seizing on this desire of people to have less choices as well.

What are others’ thoughts? Does this make sense? Should we re-envision what the work of an electronic health record is at a finer level? Am I six months ahead of my time? I can always pull this blog post out later when EHR penetration rises….

1 Comment

I took a course from Stanford this summer on "Willpower" that introduced a lot of the science around both willpower and choice. I am guessing that some of the science about what enables us to manage and develop our willpower links to executive decision-making. I subscribe to the muscle theory, which holds that you can develop your willpower by exercising it consciously, and by setting small tests daily that require willpower it will get stronger. I wonder if there's something similar to do about executive function–if you can develop it by choosing small ways that you limit choices and force decisions, and if there is a further step in user-centered design that would, as you suggest, use the knowledge to support the executive function in decision-making.

Ted Eytan, MD